Photo Credit: ICF

If the binational healthcare practitioners that ICF convened in March held one common view, it was how difficult the task was to work effectively across the border.  All worked directly with local border communities and repeatedly honed in on how routine community activities involved extensive cross-border connections and movement back and forth.  They also noted how these cross-border realities had profound implications for health determinants, disease transmission, and access to public health services.  People exposed to poor health conditions or disease in Mexico, for example, easily transmit them to California by cross-border travel.  The risks are also reciprocal:  recurrent movement back and forth across borders reinforces conditions throughout the trans-border community.  For instance, poor health conditions, disease, and risky behavior learned among community members living in the United States affected their spouses and children living in Mexico.  Many of those children will someday migrate to the United States.

The challenge faced from this experience by healthcare professionals is how to organize and sustain healthcare programs and services that adequately and appropriately match the ways in which their clients lived in this cross-border reality and how to shape their services to truly reach the various facets of their community members’ lives.  Part of the problem, they reported, involved the difficulties encountered working with Mexican agencies and colleagues who work under a different health and political system.

The obstacles are institutional, not interpersonal or cultural.  Echoing observations of participants in a National Latino Research Center (NLRC) border health 2004 study,[1] ICF Forum participants reported that their partnerships involving Mexican agencies and colleagues have been limited because of inadequate funding on that side of the border and restrictions from U.S. funders that do not allow expenditures in Mexico.  This creates a core inequality within the binational partnerships.  Mexican colleagues often feel neglected and taken advantage of, which further contributes to failed collaboration.

These problems, however, were only part of an overall dismal scene.  NLRC researchers, for example, identified four categories of impediments to border health programs.  Border health programs were characterized as having isolated and uncoordinated efforts, a weak organizational infrastructure, an absence of models or best practices to attract additional funding, and problems of sustainability.  Sustainability was perhaps the most important source of problems.  Donors often sought to support new programs with short-term results, leaving these new pilot projects as well as established programs providing routine services to struggle for annual support.

As difficult as these barriers are, however, the problems go far deeper than the need to provide more funding for existing programs.  Programs are in general short supply, and where they do exist the efforts are fragmented among a relatively long list of priorities.  For instance, across the entire U.S.-Mexico border, over 80 percent of border counties have primary care Health Professions Shortage Areas (HPSAs).  Ratios of primary care physicians to local populations are 25 percent lower in border counties than among average counties in the United States.[2]

These border healthcare problems reflect fundamental dimensions of the political and economic structure of border communities.  They are difficult to overcome.  Yet, to successfully meet the considerable health needs of the border, each must be fully addressed.

Children at Tijuana General Hospital, Photo Credit: Amy Carstensen, ICF

First, programs and services committed to community health must restructure to match the way families and individuals in the region organize their lives.  Cross-border health policies and programs, however, have been generally unable to overcome this organizational challenge.  In particular, they have not fully responded to the significance and uniqueness of what “community” means in the border region.  Community, of course, is the cornerstone of public health.  According to the U.S. Department of Health and Human Services (DHHS), health professionals have reached consensus on the close link between an individual’s well-being and the health of the community and environment in which they live, work, and play.   The World Health Organization (WHO) embraces a similar approach, focusing its initiatives on the “causes behind the causes” of illness – the social determinants of health which, according to DHHS, are profoundly affected by the “collective beliefs, attitudes, and behaviors of everyone who lives in the community.”

In a binational region, where are these collective beliefs and attitudes, the environment of work and play, if not on both sides of the border and in the behavior of crossing back and forth?  The “community” that forms the foundation for successful health care stretches across neighboring borders to link family and community members living in different locations.  Improving the health and reducing the health inequities throughout this region is the challenge and responsibility of all who work within the binational region. 

Facing the realities of cross-border communities may be the greatest initial challenge to border health, and one that has escaped decades of work on each side of the international line.  The “continum of care,” which is the strategic target of health programs, involves new dimensions when it intersects with the dispersed geographical patterns of border communities.  This continuum involves the core interconnections of different stages of an individual’s life cycle, including the sequence of exposures to various diseases, preventive behaviors, and risks encountered throughout that person’s life and range of activities.  A recent World Health Organization study demonstrates the central importance of these interconnections:

“[c]oordination along the continuum of care between safe motherhood and child survival programs is essential if substantial advances in neonatal survival are to be made. Many other types of vertical programs also affect neonatal outcomes, including family planning, immunization, sexually transmitted diseases, and HIV/AIDS. Child health programs are working to strengthen clinical care, integrate outreach services, and step up behavior changing approaches.” [4]

Strategically, a new approach to healthcare in the region must design health services, finances, and organizations to match the way families, communities, and professionals work along this continum of care.  Yet, this approach would require attention to the sequence of geographical moves and the environments which individuals encounter at different locations.  That is, the “continuum of care” in a cross-border community includes a geographical dispersion of many of an individual’s interconnected phases of treatment or root causes of poor health that may be manifested in any stage of life.  As a result, the approach requires program linkages between places of origin, their community of upbringing, the risks at the workplace, and the community in which the residents live while abroad.

In a border region, the strategic lesson is simple: an effective approach to health care at any particular time or place is completely dependent on what has happened before in that particular locale and on the other side of the border.  Health programs that are designed to prevent or treat illness that address only one location are doomed to failure.  Program organization needs to match the interconnections that exist in community members’ lives and provide a capability to intervene at all points in that web of influences.  Programs designed or limited to working on only one side of the border are unable to make headway against a set of disease risks, unhealthy behaviors, and environmental conditions that stretch beyond their reach. The staff that works on these programs needs to be equally confortable working on either side of the border or at least be willing to take the time to visit and understand the environment that their target population faces on a daily basis.

Scaling Up

A second challenge facing the private, nongovernmental and public healthcare sectors along the border is how to increase the scale of operations and impacts.  Even successful, small scale, targeted programs become self-defeating when they reproduce competitive, unorganized efforts to attack disjointed aspects of border problems.  Border health care is not alone in needing to face up to this problem.  Scaling up, as the challenge is referred to around the world, is a persistent challenge to healthcare systems everywhere.

Scaling up goes well beyond what is typically meant by capacity building along the border.   Successful capacity building efforts also need to reach a higher scale of operation that requires transformation of programs and redefines targets, tactics, and treatments.  A recent report from the WHO shows that enlarging the scope and scale of health programs, and becoming more effective for more people, requires much more than additional funding and marginally more staff or capacity.  It involves “practical, organizational transformations” and new strategic choices around health service innovations.[5]  

Scaling-up is an institution building process, however, that does not necessarily fit well with philanthropic and public sector supporters of border health programs.  The process takes time, which does not coincide with the interests of donor agencies and policymakers bent on seeing immediate results.  The institution building strategy may also be at odds with a “project-oriented” funding approach, where specific investments are expected in two or three years to deliver a narrow range of results.

Lack of a comprehensive strategy for scaling up virtually ensures failure to make progress against increasing disease risks.  It reproduces the fragmentation and weakness of the current infrastructure and reinforces perceptions that additional funding will have little impact on health outcomes.  Lessons learned from scaling up efforts around the world show that a critical component of a new strategy requires formation of a resource team to help organize a more comprehensive program and help play a strategic and ongoing catalytic role.  These teams help governments and philanthropic organizations find ways to bring change to those programs that are already showing progress, but on a smaller scale.  The team provides a collective approach to advocacy, research, and technical assistance that can make greater headway in attracting public sector support than having managers and directors campaign for their own programs.

No such resource or leadership team that focuses on the overall value and performance of binational health care currently exists in the San Diego-Baja California region. The ICF Forum participants agreed that government agencies do not provide an umbrella leadership structure for their programs, although the USMBHC is developing this role.  Given the range of public sector problems on both sides, Forum members also thought one such organization would be insufficient for this task.  The group acknowledged that the key missing element in the binational region’s leadership on health was the private sector.  Private business, working as strategic partners, with philanthropy and community-based organizations and USMBHC had a much greater opportunity than governments to identify innovative and coordinated approaches to cross-border health challenges.  The business sector recognizes the potential benefits in developing cross-border projects in areas such as clinical trials for pharmaceuticals. Mexican communities would also benefit from increased foreign investment by improving the health infrastructure, enhancing the capacity of health professionals and increasing access of the population to new therapies[6].  Philanthropic organizations have the flexibility to play a key niche role in providing support to the resource teams and pilot tests, while private entrepreneurs had the expertise to organize activities at a scale that might actually meet the actual size of the risk and opportunity. The USMBHC could house the umbrella function of all working together.

A third barrier to effective cross-border health is systemic and, as such, much more difficult to overcome than even the two challenges discussed above – designing to meet the geographically dispersed continuum of care and the need to increase scale.  The third barrier involves an “institutional mismatch” that undermines the ability to work across borders.  In short, health care entitlements are national in nature, the responsibility of each government to take care of the “general welfare” of its own people.  Yet, in a border community where people and families live on both sides of the border, and their health is clearly linked to environments and activities on each side, this national responsibility is misaligned with what people need and they way they organize their own lives.

Institutional authorities that define eligibility for service and decide on the availability of resources are rooted in government jurisdictions which do not have the capability or even obligation to respond and serve cross-border community members.  Treating the border region as a whole is imperative to serving these communities.

This institutional mismatch between jurisdictions and communities, quite simply, is a form of structural disenfranchisement and disempowerment.  Which government represents a community that has part of its members inside one state and part in another?  To which institution does a community as a whole turn or petition for help if the institution itself does not cross the border and have authority to work on both sides.  In this binational region, the two governments have radically different approaches to public health.  Under the Mexican Constitution, public health is a federal responsibility and the primary policy decisions are made by officials in Mexico City, in some cases in the state capital, but seldom at the local level.   In the United States, public health is a state responsibility, often with authority for decision-making resting legally with county officials.  The result is fragmentation of authority and responsibility, overly complex and complicated organizational structures, and non-responsive public authorities.  Local communities, officials, and business people are stymied by distant or disjointed capabilities and perspectives.  While this is so, it is worth noting that the USMBC was created, in part, to bring both countries together at least among governmental agencies: local, state and federal.

Participants in both the 2004 NLRC study and the 2006 ICF Forum talked about the effects of this mismatch.  At a community level there was no shortage of informal, interpersonal negotiations between Mexican and U.S. officials.  Some of the most successful project fund-raisers were among the best ‘negotiators.’  However, as heroic as these creative efforts have been, they undermine a capacity to deliver adequate service and organize a strategy for health care that could have a sustained impact in the region.  What should be a formal structure of responsibility, even a right from an individual’s perspective, remains a persistently contested matter of separate negotiations.

Children’s Physical Exams at the Health Fair in San Ysidro Health Center Photo Credit: Elizabeth Santillanez

Institutional mismatches are not as daunting a challenge, however, as they may first appear.  Similar misalignments between jurisdictional authority and the ways in which communities organize themselves are fairly familiar in the United States where urban sprawl has pushed the realities of economic and social life beyond traditional city boundaries and responsibilities.  Metropolitan economies and communities have replaced the sole authorities of city and county as people routinely travel back and forth to work, shop, visit, and live.  Institutions of authority, including traditional community and neighborhood-based associations, no longer have power over all parts of the activities important to their citizens, residents, and members.  Mayors can only partially influence the local economy, for instance, if many of those who work in the city live in the suburbs, are taxed under a county’s jurisdiction, and vote in totally separate elections.  No one government entity, no single organization, represents the interests, assets, and desires of the people who organize their lives on this regional as opposed to city scale.

Of course, when communities and economies “sprawl” across boundaries that represent national governments, the severity of the institutional mismatch becomes itself a defining feature of community organization.  Members of the same community are separated from each other, disenfranchised from participating in activities that could otherwise serve the entire group, and unable to seek service from a single entity.  No government, health care institution, or organization is accountable to these cross-border community members.  One reason immigration policies and politics become central to discussions of health care is that the movement of community members confronts this fundamental mismatch – which government serves the person who is moving  between locations throughout our binational region? 

These mismatches, of course, are not unique to the U.S.-Mexico border.  In Europe, where cross-border health issues have long been a target of European Community-wide integration efforts, this mismatch between institutional authority and social needs is discussed as a problem involving the ‘principle of territoriality.’  Despite successive revisions of the European Community Treaty in hopes of addressing the health problems of cross-border integration, health care delivery remains primarily a matter of national competence and responsibility.  Funding schemes limited to social security, taxation or other nationally-based systems ensure that those jurisdictions must retain authority over eligibility, coverage, and quality.

The European Community, however, also struggles with ways to transform its health care system beyond this territoriality principle to find ways to more adequately and appropriately serve workers, families and professionals moving across its many borders.  For example, governments have reached agreements to guarantee health coverage to migrant workers and their families.  Although some problems related to these workers’ eligibility for services on both sides of the borders have arisen, the more prominent challenge remains how to educate and encourage access to health care for those whose health expenses are not covered on either side of the international lines.[7]

The European Community has also worked to improve the access for health professionals to contract and perform services across borders.  On a much smaller scale, California and Mexico have tentatively wrestled with similar steps to facilitate healthcare in a cross-border community.  Over the last few years, for example, the California legislature has debated legislation that would allow small numbers of Mexican doctors and dentists to practice in California for a limited number of years.[8]  Such programs would provide much needed healthcare professionals to help serve the working poor, especially in rural areas.  They would also help reduce state medical costs, delivering care more efficiently and less costly than in current programs and practices that often produce uncompensated care for services in emergency centers.[9]

Not surprising, the strongest source of controversy about these limited cross-border programs has come from public and private jurisdictions that represent people in different parts of the community.  State of California officials, for instance, have worried about the standards of training and the fairness of the distribution of care.  The private California Medical Association has opposed rules of program participation and the practice of medicine that are different than those which govern California physicians.  Also, it may be difficult to keep these professionals in the truly needy areas.  The possibility of a permanent location in the United States tempts many and they often want to move to the more affluent areas to practice.   On the Mexican side, health authorities have barely enough resources to provide basic health care to a huge number of people and complain that U.S. visitors in need of services while in Mexico have the expectation that they will be provided with comprehensive care equal to what they are used to in the U.S.

Still, as difficult as these innovative programs may be to organize, they represent promising approaches to the realities of health risks in a cross-border economy and community.  They also stand in stark contrast to current government policies, many foundations’ rules and strategies, and even the practices of most community development programs along the border.  These existing approaches limit their work to only a fraction of the community dimensions that determine current and future health conditions, risks, and opportunities for improvement.  Ultimately, this limitation calls into question whether current strategic programming is simply designed to fail.  Incomplete program designs compromise care, sever services, and diminish the capacity of community members to mobilize and help themselves.  There is a kernel of a good solution in these guest programs but they need a lot more work and compromise to become a reality for the most needy.